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DECIDING ON DISCIPLINE CASE Failing to Check the DIN Resulting in a Dispensing Error Member: Name withheld (The member’s name has been withheld due to the member’s acquittal) The member was alleged to have committed an act of professional misconduct in that he/she breached a standard of practice of the profession by dispensing 3TC® when Combivir® was prescribed. While the member did not dispute the facts, he/she argued that his/her actions in connection with the dispensing error did not amount to professional misconduct. In a contested hearing, a panel of the Discipline Committee found the member not guilty of professional misconduct. The Facts The complainant attended a pharmacy, at which the member was employed, for a refill of a prescription for Combivir®. However, the complainant was dispensed 3TC® which he/she took for about two weeks before the error was discovered. Upon being notified of the error, the member immediately acknowledged that: • In filling the prescription for Combivir®, he/she picked up a bottle of 3TC® in error and placed a computer generated label on the front of the bottle of 3TC® indicating that he/she had dispensed Combivir® • On the day the dispensing error occurred, the pharmacy was busy and he/she was working alone • While the member wrote down the DIN from the 3TC® bottle onto the prescription hardcopy for the Combivir® and intended to compare the two DINs, as was his/her usual practice, the member did not check the DIN numbers to ensure the medication dispensed was the medication prescribed • Finally, upon discovery of the error, the member managed the error appropriately in that the member acknowledged that the error occurred, extended an apology and followed up Legal Argument The College took the position that failing to compare DIN numbers constituted a breach of a professional standard. If a professional standard was breached, legislation mandated the panel to find the member guilty of professional misconduct. In its submissions, the College cautioned the Panel not to characterize the member’s conduct as simply a one-time breach that did not warrant discipline, as this characterization was not in the interest of the public or the profession. What was involved was a fundamental departure from established pharmacy practice. 26 Pharmacy Connection March • April 2004
By contrast, the member argued that there was no breach of any standard of practice. This one-time isolated incident constituted simple human error for which the member took full responsibility. The standard on which both parties relied to assert their respective positions was Standard 1 of the Standards of Practice: “The pharmacist, using unique knowledge and skills to meet a patient’s drug-related needs, practices patient-focused care in partnership with patients and other health care providers, to achieve positive-health outcomes and/or to maintain or improve quality of life for the patient.” The College argued that, in addition to the standard above, there are other unwritten standards understood and practised by members that provide the detail of what is expected in Standard 1. Comparing DIN numbers, although not explicitly stated, is what “patient-focused care” requires in dispensing circumstances to achieve “positive health outcomes”. Comparing DINs is a reasonable expectation of a competent pharmacist, in such circumstances, to ensure that the right drug is dispensed. Accordingly, failure to take this step is a failure to maintain a standard of practice of the profession and hence, professional misconduct. By contrast, the member argued that the standards of practice that members are required to comply with are those written by the College. To date, there is no written standard requiring the comparison of DIN numbers, thus there can be no breach and hence, no finding of professional misconduct. In the member’s submission, the critical fact was that the member’s response was appropriate according to Operational Component 1.8 of Standard 1: “The pharmacist assumes responsibility for medication discrepancies and errors, takes the necessary steps to resolve issues arising from them, and implements measures to prevent recurrence”. The member argued that this standard assumes that people make mistakes and that his/her response to the mistake was appropriate. Reasons for the Decision The panel dismissed the allegations against the member. While the panel agreed with the College that the “standards of practice” are not limited to the Standards of Practice as published by the College, it agreed with the member that even those unwritten standards do not say that every person who makes an error has breached a standard of practice. The panel further characterized the checking of the DIN as an appropriate procedural protocol, and also distinguished a procedural protocol from a standard of practice. More specifically, in the circumstances of this case, the panel considered that the member therefore did not breach a standard of the practice in that: • While there was an attempt to use the DIN number to verify the accuracy of the prescription, an error was made in that process • The member acted as a reasonable competent professional and followed a reasonable procedure. However, due to an error he/she did not complete a procedural protocol of visually comparing the DIN. Therefore, he/she breached an accepted procedural protocol and not a standard of practice • When the member realized the error, he/she acted in an appropriate manner • The member’s testimony that comparing DIN numbers was his/her practice demonstrated awareness of the steps that are needed to accurately dispense the prescription • Simply because an error occurred does not mean that appropriate knowledge was not applied Pharmacy Connection March • April 2004 27
Page 1 and 2: March/April 2004
Page 3 and 4: Ontario College of Pharmacists 483
Page 5 and 6: REGISTRAR’S MES S AGE Deanna Will
Page 7 and 8: Thursday, April 15 - Newmarket - Di
Page 9 and 10: Stephen Mangos Public Member Chair,
Page 11 and 12: Mixing One or More Medicines or Nat
Page 13 and 14: Advice or Written Information Recei
Page 15 and 16: Correct Uses of the Symbol* • Com
Page 17 and 18: PHARMACY ACCREDITATION RENEWALS 200
Page 19 and 20: HEALTH CANADA Advisories & Notices
Page 21 and 22: INSPECTORS’ CORNER INSPECTORS’
Page 23: Date Location** Workshop Type Topic
Page 27 and 28: International Pharmacy Graduate Pro
Page 29 and 30: For example, the addition of an ang
Page 31 and 32: B U L L E T I N B O A R D PIPEDA In
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